Virtual Consent Form And Instructions

Virtual Consent Form Instructions
1. Please print out and complete the Consent Form on the following page.

2. Sign Consent.

3. Scan and email signed Consent Form to: info@travisshawmd.com

Help with Scanning?

If you do not have dedicated scan to email capability, try:

iPhone:

Open the Notes app (yellow notepad Tap the icon in lower right to create a new note. Select the camera icon. Select “scan Documents” and follow the instructions. Select “Keep Scan” to save the file. Send file by selecting the Send/Share icon in the top right.

Select the Mail app and email to: info@travisshawmd.com.
Android:

Open the Google Drive app. In the bottom right, tap Add. Tap Scan. Take a photo of the document you would like to scan. Adjust scan area: Tap Crop. Take photo again: Tap Re-scan current page. To save the finished document, tap Done.

Send to: info@travisshawmd.com

Travis Shaw, MD
Consent to Participate in a Virtual Consultation
Name:
Name

First Name Last Name
Date:
Date

Month Day Year
Date
I understand that my healthcare provider, Travis Shaw, M.D. has invited me to participate in a virtual consultation.

My healthcare provider has explained to me how the virtual consultation will not be the same as a direct consultation, due to the fact that I will not be in the same room as the healthcare provider.

I understand that there is potential risk with this technology, including interruptions, unauthorized access, and technical difficulties.

I understand that my healthcare provider and myself can discontinue the virtual consultation if it is felt that the videoconferencing connections are not adequate for the situation.

I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes (if applicable I may request the following: (1) omit specific details of my medical history/physical exam that are personally sensitive to me: (2) terminate the consultation at any time.

I have had the alternatives to a virtual consultation explained to me, and in choosing to participate in a virtual consult, I understand that a complete consultation may not be performed and I will require an in person exam prior to having procedures or surgery, should I choose to do so.

In an emergent consultation, I understand the responsibility of the telemedicine healthcare provider may be to direct my care to a local healthcare provider and the healthcare provider’s responsibility will conclude upon termination of the virtual consultation.

I understand that with any internet platform there is a risk of HIPAA violation or hacking of content in the unlikely event of internet hacking of a server’s content.

No recording will be performed without explicit consent by me and my healthcare provider.

I have read this document carefully and understand the risks and benefits of a virtual consultation and have had my questions regarding this consult explained and I hereby consent to participate in a telemedicine visit under the terms described herein.
Signature

Clear
Email
example@example.com
Date of Birth:
Date of Birth

Month Day Year
Best Phone Number To Reach You:

Area Code Phone Number
Address:
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Should be Empty:

Virtual Consent Form Instructions

Travis Shaw, MD

Consent to Participate in a Virtual Consultation

Name:

Date:

Date of Birth:

Address: